Bioethics

How Much Freedom Should We Give Up To Avoid the Spread of Infectious Diseases?

The first patient to be diagnosed with Ebola outside of West Africa has been reported. He is now in the US, receiving treatment. He arrived from Liberia via Brussels before reporting symptoms, which were initially mis-diagnosed and treated with antibiotics.

If I were in West Africa and I had reason to fear I had been exposed to Ebola, do you know what I would do, if I had the resources? I would not wait to see if symptoms appeared or to be diagnosed, I would fly to the US or Europe, where, if symptoms developed, I would receive the very best health care in the world, including experimental treatments, in front of the world’s media.

If I could afford it, even selling everything, I would get on that plane to freedom, or at least a chance. A better chance to live.

But of course along the way, I would expose others to the risk of infection, and I would risk introducing the infection to areas of the world that are currently Ebola-free. It is unlikely, even so, that it would reach the levels seen in West Africa, as these countries have the resources and infrastructure to implement more effective containment strategies. Nevertheless, there is a chance that some people would die.

So how much freedom should people have? Should our freedom to travel be balanced against the risks it might pose to others?

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Iterated in vitro reproduction and genetic orphans

In an article soon to be published in the Journal of Medical Ethics, Rob Sparrow imagines a procedure via which multiple generations of human embryos might be created in the laboratory. Egg and sperm cells would first be generated from existing or new human pluripotent stem cell lines. The resulting eggs would be fertilised using the sperm to create zygotes and ultimately embryos. Embryonic stem cells would then be harvested from these embryos and used to create new egg and sperm cells, which would in turn be used to fertilise one another to create further embryos. This process could be iterated, in principle indefinitely.

Let’s call this procedure ‘iterated in vitro reproduction’ (Sparrow calls it ‘in vitro eugenics’). Iterated in vitro reproduction is not yet possible, but, citing recent developments in the science of stem cell-derived gametes, Sparrow argues that it may well become so, though he acknowledges are number of significant hurdles to its development. He also discusses a number of possible applications of the technology and calls for an ethical debate on these. The most controversial application would be in the creation of designer children. Consider the following case, which is a variant on one of the scenarios imagined by Sparrow:

Jack and Jill present to a fertility clinic. Jack provides a sperm sample, and fertility doctors harvest a number of eggs from Jill. These eggs are fertilized with Jack’s sperm to create embryos, from which embryonic stem cells are derived. These stem cells are then induced to develop into eggs or sperm which are used to fertilise one another, and so on. The process is iterated numerous times, and at each stage, the embryos are genetically screened via pre-implantation genetic diagnosis. This screening is used to inform a process of selective crossing, so that, over several generations, the population of embryos evolves towards certain genetic dispositions desired by Jack and Jill (a disposition towards longevity, say). This process is aided by adding small amounts of genetic material from stem cell lines derived from other individuals. Eventually, doctors identify an embryo with almost exactly the desired combination of genes, and this embryo is implanted into Jill’s womb and carried to term. A child, Jarvis, is born.

Cases like this raise numerous ethical issues, some of which are discussed by Sparrow and the seven commentators on his paper. However, they also raise an interesting conceptual question: would the users of such a technology be the genetic parents of the resulting offspring? Would Jack and Jill be the genetic parents of Jarvis?

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A Right to Die in Prison?

Frank Van Den Bleeken wants to die.  He is not physically ill, but claims to be suffering from persistent mental anguish, from which death will provide him with some release.  And as a Belgian man, living in Belgium, we might ordinarily expect him to be able to take advantage of that country’s fairly liberal euthanasia laws.  Whereas many of the assisted dying regimes around the world specify that the person who wants to die must be terminally ill to qualify, Belgium has seen several cases in which people have been helped to die for reasons that do boil down to psychological distress: in a couple of fairly well-reported cases, Marc and Eddy Verbessem were deaf twins who feared blindness and sought death on that basis, and Nathan Verhelst sought it in the wake of unsuccessful gender-reassignment surgery.

What makes Van Den Bleeken particularly newsworthy is this: he is a convicted killer and rapist.  According to the CBC, he had argued that “he had no prospect of release since he could not overcome his violent sexual impulses and so he wanted to exercise his right to medically assisted suicide in order to end years of mental anguish”.  It’s not clear whether the anguish came from being in prison, or guilt, or something else.  This might make a difference; I’ll touch on that below.

What should we say about the morality of such a case? Continue reading

Playing the game: a story for the pool-side sun-lounger

It’s still summery, and so here is a little story for the beach or the side of the pool

‘There are challenges, certainly’, said the Boss. ‘But we’re confident that we can meet them. Or at least’, he went on, looking over his glasses for signs of dissent, ‘for a critical mass of stakeholders’.

A graph appeared on the screen at his side. He traced its lines with a red laser dot.

‘Here’, he said, ‘we have the expected rise of temperature with time. And here’ (he stabbed with the dot, as if doing the killing himself), ‘we have the consequent reduction in human population – assuming’ (and he held up a schoolmasterly finger), ‘we don’t have any HR66.’

He sipped some water, and waited for this to sink in. It did.

‘But don’t worry’, he said. ‘There’s good news. We do have HR66. Not enough for everyone, sadly, but enough to ensure that the human baton is passed on. And enough, I’m glad to say, for everyone in this room.’

There was a ripple of relief.

‘And their families, of course’, the Boss continued. ‘Families are very important to us. But all this assumes that you want to have the HR66. No one will make you. But, frankly, what’s not to like? You take a single dose, and you survive. If you don’t take it, you don’t survive. It’s as simple as that. It even tastes of candy floss. It has only one side-effect, and that’s a wholly good thing. It increases – increases, mark you – your IQ. Very, very significantly. By about 100 points, in fact. Not only will you be alive; you’ll be a genius beside whom Einstein would have seemed a hopeless retard.’

One more press of the button, and up flashed the logo of the corporation that manufactured HR66. The Boss didn’t think it relevant to mention his shareholding.

‘Naturally’, said the Boss, ‘we have to vote for this in the usual way. Yes, humanity’s facing apocalypse, and there’s one, and only one way out. But we’ve still got to do things properly. But I expect that we can move to a vote now, can’t we?’

‘I’m sure we can’, agreed the Deputy. ‘You’ve all seen the motion. All those in favour….’

‘One moment’.

The Boss and the Deputy, up on the podium, stared. Everyone else turned. A little man in tweed lisped through a badger’s beard. ‘I’d like some clarification, please.’

‘But of course, Tom’, said the Boss, magnanimous and desperately alarmed. ‘Anything you like.’

No one really knew how Tom had got into the government, or why he wanted to be there. He had no strategically significant connections, no dress sense, no publications other than some monographs on moths and mediaeval fonts, no assets other than a dumpy wife, some anarchic, unwashed children and a small cottage on Dartmoor, and no entries in the Register of Members’ Interests apart from ‘Masturbation’. This entry had caused a terrible storm. He’d been accused of injuring the dignity of the House, but, after expensive legal advice had been taken, it had been ‘reluctantly concluded’ that there was no power to force him to remove it.

‘I’d like to know’, said Tom, ‘who’s going to get the drug. And why them rather than anyone else.’ Continue reading

Ebola, ethics and the WHO’s decision

The World Health Organization on Monday announced the outcome of its ethical deliberations. It found that, in certain circumstances, it was ethically permissible to use unproven drugs on Ebola patients.

It then listed ethical criteria. These included transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity and involvement of the community.

These are laudable principles but what do they actually mean in practice? The devil is in the detail. If you broke your ankle after slipping on coffee in a hotel, and asked a lawyer if you would win a case against the hotel, you would be frustrated if the lawyer simply recited a legal principle: “the hotel owes you a duty to take reasonable care to see that you are reasonably safe in using the premises”. You want to know whether, in your case, the hotel did take reasonable care. To resolve your problem, the legal principle must be applied to the facts.

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Ethics of Ebola and Potentially Life-Saving Experimental Treatment

Summary: Patients potentially infected with Ebola have the right to experimental treatment outside of randomised controlled trials. Consent should be sought while they are competent if it is anticipated that they will lose competency through the disease. In the most extreme emergencies, experimental treatment could be given without consent in the public interest. However, in such extreme emergencies, such if the virus were to mutate to become very highly transmissible, selection of patients for such trials should be on a principle of justice. This would generally require selecting patients with the worst prognosis as initial subjects. Whilst the current outbreak has been declared an international health emergency, it does not warrant over-riding standard ethical principles of consent and autonomy.

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WHO are convening a meeting next week to discuss the use of untested treatments for the current Ebola outbreak, which it has declared to be an international public health emergency.

Dr Marie-Paule Kieny, Assistant Director-General at the World Health Organization explained “We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,”

With a fatality rate of recent outbreaks at around 50%, and current treatments consisting of little more than rehydration, it is easy to see why this experimental approach is an attractive option. Jeremy Farrar, David Heymann and Peter Piot argued convincingly in favour of such measures.

However, there are a number of diseases which meet Dr. Kieny’s criteria of “a high fatality rate without any proven treatment or vaccine”. While Kieny is referring to infectious disease, sufferers of other diseases have campaigned for many years for access to untested medicines. Along with several colleagues, I wrote a paper on this subject with Les Halpin, who recently died from motor neurone disease, having campaigned for access to medicines for many years

The case for

I have argued that, when a patient is facing a certain death from an incurable disease, the relative safety that randomised controlled trials provide is unnecessary- especially when the payoff is a placebo group of patients who receive no benefit at all.

One common reason in support of randomised controlled trials is safety. This is true for most patients: patients for whom there are other good treatment options, or whose disease is not itself life-threatening. But for some patients, this concern is a cruel irony. Their disease is so overwhelmingly unsafe that any risk is outweighed by potential benefits. Udo Schuklenk reports Martin Delaney, a trial patient for AIDS who described the situation vividly:

It is as if I am in a disabled airplane, speeding downward out of control. I see a parachute hanging on the cabin wall, one small moment of hope. I try to strap it on, when a would be government employee reaches out and tears it off my back, admonishing, ‘You cannot use that! It does not have a Federal Aviation Administration sticker on it. We do not know if it will work’

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Lord Falconer’s Assisted Dying Bill: Is Slow Assisted Dying Legal?

In 2005, the NZ Herald reported. “A man with motor neurone disease plans to starve himself to death rather than wait to die.

“Thirty-nine-year-old Andrew Morris of Hamilton has limited movement and can barely speak. He has gone public with his decision because he wants law changes to allow voluntary euthanasia.”

Such cases occur not infrequently, around the world. Last month, John Rehm took his life by dehydration. NBC News reported:

Diane Rehm and her husband John had been married for 54 years when he knew he didn’t want to live another day.

His Parkinson’s disease had become unbearable. “He just kept getting weaker,” the NPR host told NBC News. “We called in the doctor and John said to him: ‘I am ready today.’ He said ‘I can no longer use my legs, I can no longer use my arms, I can no longer feed myself.’ And knowing with Parkinson’s it is going to get worse rather than better, he said ‘I wanted to die.’” He asked the doctor for help.

The answer they got surprised and disappointed both of them. “The doctor said ‘I cannot do that legally, morally or ethically’,” Rehm said. “He said ‘I don’t disagree with your wish that you could die with the help of a physician but I cannot do it in the state of Maryland.’”

John Rehm had to deliberately die by dehydration. It took nine days.

“John said he felt betrayed,” Rehm said. He said, ‘I felt that when the time came, you would be able to help me.’”

In a recent, short commentary on the sad case of Tony Nicklinson, I argued that two basic moral rights effectively equate to a legal right to slow assisted dying. In one sense, Rhem’s doctor was wrong.

Firstly, everyone, including Mr Hamilton, has a basic right to control what goes into their bodies, including food and fluids. Everyone has a basic right to refuse to eat and drink, even if this results in their death.

Secondly, everyone has a basic right to health care, including the relief of pain and suffering. As someone is dying, they have a right to palliative care to achieve that end. This includes the administration of narcotics and sedatives, as necessary to relieve their suffering and as requested by the patient. This is so, regardless of whether their suffering is self-inflicted or not.

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Economic arguments and assisted dying.

by Dominic Wilkinson (@NeonatalEthics)

Lord Falconer’s assisted dying bill is being debated today in the House of Lords. In the past week or two there has discussion in the media of many of the familiar arguments for and against such a proposal. As Roger Crisp noted in yesterday’s post, there have been relatively few new arguments. Supporters of the bill refer to compassion for the terminally ill, the difficulty of adequately relieving suffering, and patients’ right to make fundamental choices about the last stage of their lives. Opponents of the bill express their compassion for the terminally ill and those with disabilities, fear about coercion, and the omnipresent slippery slope.

One concern that has been raised about the assisted dying bill is the fear of abuse in the setting of an overstretched public health system. For example, Penny Pepper, writing in the Guardian notes that “Cuts to social care are monstrous…How would the enactment of the Falconer bill work if brought to our harassed NHS?”

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Would Legal Assisted Suicide be the Final Triumph of Market Capitalism?

Tomorrow  in the House of Lords Lord Falconer’s bill on assisted dying will be debated. The bill would allow those who are terminally ill and likely to die within six months to request life-ending drugs from their doctor for the patients to use as and when they see fit.

As might have been expected, there has been huge discussion over the bill, but most of the arguments presented so far are not new, and the same will probably be true tomorrow. But there is one I haven’t seen before, put forward recently by Giles Fraser: that assisted suicide is the ‘final triumph of market capitalism’. Continue reading

The pill to banish painful memories—forget it!

It is a curious feature of the late 20th and early 21st centuries that the media regales readers and viewers almost daily with exciting details of breakthroughs in medical science: new cures, reversals of previous certainties about old remedies (and then, often enough, later reversals of the reversals), astonishing information about our brains and numerous other organs, apparently dramatic discoveries about free will and ethical thinking. Much of this is indeed attributable to the rapid rate of the expansion of contemporary scientific understanding which we should not want to underestimate, but it is also sometimes the result of the media’s excitability and search for sensation, combined with the impressive self-promotional skills of practitioners of the medical sciences. This latter factor means that reported “breakthroughs” are often no more than confident early steps on a promising but uncertain path, and when they lead nowhere this sad news tends not to see the light of day. And then there are the cases of outright fraud or incompetence, such as the South Korean scientist Hwang Woo-suk’s initially much-proclaimed breakthroughs in the early 2000s in stem cell research that were shown to be faked.

So a certain reserve about reported breakthroughs is in order, but a recent case is worth philosophical scrutiny even if its claims turn out to be less valid than they seem. This was a report in The Mail Online, Science and Technology section that was headlined “Could Pill wipe out bad memories? Drug used to treat multiple sclerosis found to help us forget experiences that caused us pain.” But it turns out that the drug has only been tested for memory erasure of pain in mice, and then only of a specific type of pain associated with mild electric shock. The Mail article jumps rapidly from this modest beginning to claim that the experiment “offers hope of a drug that could eradicate memories of traumatic events from years ago and help patients overcome phobias, eating disorders and even sexual hang-ups.” For none of this “hope” is there an iota of evidence in the scientific study and one of the scientists involved in the study at the Commonwealth University of Virginia, Dr Sarah Spiegel, showing appropriate modesty, said of the drug concerned: ‘Fingolimod, a Food and Drug Administration approved drug for treatment of multiple sclerosis, has beneficial effects in the central nervous system that are not yet well understood.” More ambitiously she added: “Fingolimod deserves consideration as an adjuvant therapy for post traumatic stress disorder and other anxiety disorders.”

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